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ADV Health Assessment & Clinical Reasoning > Health Assessment Final > Flashcards

Health Assessment Final Flashcards

1
Q

The number of muscle fibers is determined in utero we are born with the # of muscle fibers we will have for life over time the muscle fibers lengthen

A
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2
Q

When is bone growth completed and the peak bone mass achieved? Why is this important

A

Bone growth is completed at 20 years old but peak bone mass is achieved at 35 years old.

Having a balanced diet is essential, crash diets are bad. You are building the strength of the bones during this time esp for menopause and later years.

The balanced diet and increased calcium will decrease the chance of osteopenia, osteoporosis and fractures

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3
Q

How does being pregnancy affect the MS system?

A

Increase mobility of pelvic joint

Lordosis of spine (inward forward curvature) Waddle gait

Lower back pain

Muscle cramps

Increased fluids increase risk of carpal tunnel syndrome

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4
Q

How is the MS system of the older adult affected?

A

Alteration of the equilibrium between bone deposition and bone reabsorption results in Loss of bone density esp vertebrae and long bones

Higher risk of fx

Deterioration of joint cartilage

Decreased mobility

Muscle mass decreases

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5
Q

Axial Skeleton

A

Appendicular Skeleton

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6
Q

HUMAN

SKELETON

AP VIEWS

A

Skeletal muscles from anterior and posterior views.

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7
Q

Articular Structures

A

include joint capsule and articular cartilage, synovium and synovial fluid, intra-articular ligaments, and juxta-articular bone

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8
Q

Extra-articular structures:

A

include periarticular ligaments, tendons, bursae, muscle, fascia, bone, nerve, and overlying skin

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9
Q

Ligaments connect

A

Bone to Bone

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10
Q

Tendons Connect

A

Muscle to Bone

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11
Q

Synovial Joints

A

Freely movable

•Freely moving articulations containing ligaments and cartilage covering the ends of the opposing bones that are enclosed by a fibrous capsule

·eg: Knee, shoulder

•Synovial membranes line the joints and secrete the serous lubricating synovial fluid

MOST JOINTS ARE SYNOVIAL

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12
Q

Cartilaginous Joints

A

◦Slightly movable

◦

·eg: Vertebrae

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13
Q

Fibrous Joints

A

◦Immovable

◦

·eg: Skull sutures

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14
Q

Synovial Joint

Spheroidal
(ball and socket)

A

Type of Joint: Convex
surface in
concave cavity

Articular Shape: Wide-ranging flexion, extension, abduction, adduction, rotation, circumduction

Ex: Shoulder, hip

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15
Q

Synovial Joint

Hindge

A

Articular Joint: Flat, planar

Movement: Motion in one plane; flexion, extension

Ex: Interphalangeal joints of the hand and foot; elbow

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16
Q

Synovial Joints

Condylar

A

Articular Shape: Convex or concave

Movement: Movement of two articulating surfaces
not dissociable

Ex: Knee; temporomandibular joint

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17
Q

Bursae

A

develop in the spaces of connective tissue between tendons, ligaments, and bones to promote ease of motion at points where friction would occur

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18
Q

Wrist

(Radiocarpal Joint)

A

•Articulations of:

  • •Radius and carpal bones
  • •Proximal and distal row of carpal bones
  • •Articular disc, ulna and carpal bones

Flexion and extension

Rotational movement

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19
Q

Hand

Articulation of:

A
  • Carpals and metacarpals
  • Metacarpals and proximal phalanges
  • Middle and distal phalanges
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20
Q

Forearm

Articulation of:

A
  • Articulations between radius and ulna at both proximal and distal locations
  • Pronation and supination
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21
Q

Elbow

A
  • Articulation of humerus, radius, and ulna
  • Enclosed in a single synovial cavity
  • Ligaments of the radius and ulna protecting the joint
  • Bursa lies between olecranon and the skin
  • Hinge joint permitting movement in one plane (flexion and extension)
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22
Q

Shoulder

(Glenohumeral joint)

A
  • Articulation between the humerus and the glenoid fossa of scapula
  • Ball-and-socket joint that permits movement of the humerus in many axes
  • Acromion and coracoid processes and ligaments between them form arch surrounding and protecting joint
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23
Q

What are the shoulder and position of the humeral head stabilized by

A

Rotator cuff

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24
Q

What Muscles and their tendons comprise the rotator cuff

A

Supraspinatus

Infraspinatus

Teres minor

Subscapularis

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25
Q

Acromioclavicular Joint

A

•Articulation between the acromion process and the clavicle

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26
Q

•Sternoclavicular joint

A

Articulation between the manubrium of sternum and clavicle

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27
Q

•Temporomandibular joint (TMJ)

A
  • Articulation between the mandible and temporal bone in the cranium
  • Hinge action opens and closes mouth
  • Gliding action permits lateral movement, protrusion, and retraction of the mandible
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28
Q

What vertebrae comprise the spine?

A

•Spine

  • •Cervical vertebrae
    • •Thoracic vertebrae
  • •Lumbar vertebrae
  • •Sacral vertebrae
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29
Q

Fibrocartilaginous disks separate vertebrae and are found….

A

Everywhere but the sacral vertebrae

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30
Q

Each disk has a ________ of __________ that cushions the vertebral bodies

A

Nucleus of fibrogelatinous

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31
Q

Vertebrae form a series of

A

joints that glide slightly over each other’s surfaces

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32
Q

Which vertebrae are the most mobile?

A

Cervical

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33
Q

Flexion and extension occur between the _____ and ______. Rotation occurs between _______ and _______

A

Flexion and extension occur between the skull and C1; rotation occurs between C1 and C2

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34
Q

_______ vertebrae are fused and, with the coccyx form the posterior portion of the pelvis.

A

Sacral

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35
Q

Hip joint

A
  • Articulation between the acetabulum and the femur
  • Ball-and-socket joint, permitting movement of the femur on many axes
  • Three strong ligaments support joint
  • Three bursae reduce friction in the hip
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36
Q

Knee

A
  • Articulation of the femur, tibia, and patella
  • Hinge joint, permitting movement (flexion and extension) between the femur and tibia on one plane
  • Articulation of the femur, tibia, and patella
  • Fibrocartilaginous disks (medial and lateral menisci) cushion the tibia and femur and are attached to the tibia and the joint capsule
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37
Q

What gives medial and lateral stability to the knee

A

Collateral ligaments

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38
Q

What adds anterior and posterior stability to the knee

A

•Two cruciate ligaments cross obliquely within the knee, adding anterior and posterior stability

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39
Q

__________ ___________ separates the patella, quadriceps tendon, and muscle from the femur

A

The suprapatellar bursa separates the patella, quadriceps tendon, and muscle from the femur

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40
Q

Ankle

(tibiotalar joint)

A
  • Articulation of the tibia, fibula, and talus
  • Hinge joint that permits flexion and extension (dorsiflexion and plantar flexion) in one plane
  • Additional joints in the ankle, the talocalcaneal joint (subtalar) and transverse tarsal joint, permit it to pivot or rotate (pronation and supination)
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41
Q

Foot

A
  • Articulations of the foot between the tarsals and metatarsals, the metatarsal and proximal phalanges, and the middle and distal phalanges
  • Flexion and extension
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42
Q

MS system

Infants and children

A
  • Long bones increase in length and thickness throughout childhood
  • Cartilage in smaller bones ossifies
  • Ligaments are stronger than bones until adolescence
  • •Fractures common
  • Muscle fibers lengthen
  • Skeletal system grows
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43
Q

MS system

Adolescents

A

•Rapid growth in puberty results in:

  • •Decreased strength in epiphyses
  • •Increased risk for injury
  • Bone growth completed about age 20
  • Peak bone mass achieved at age 35
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44
Q

Common or Concerning Symptoms

MS System

A

Low back pain

Joint pain, stiffness, swelling, redness, Decrease ROM, trauma

Muscle pain (Cramp) or weakness

Inflammatory or infectious joint pain

Joint pain with systemic features such as fever, chills, rash, anorexia, weight loss, weakness

Joint pain with symptoms from other organ systems

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45
Q

Approach to Musculoskeletal Complaints

A

Algorithm for Low Backpain

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46
Q

What if the physical examination sequence for MS?

A
  • Observation:
  • Palpation
  • AROM (active Range of Motion) if abnormal PROM (Passive ROM)
  • Muscle strength (observe during AROM, and against resistance)
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47
Q

Physical Exam of Musculoskeletal Assessment of a Joint pathology

A
  • If the joint is painful assess it last.
  • So first assess joint on the opposite side if available
  • Then proximal and distal joints on the same side
  • Finally the painful/pathologic joint
  • •For instance: Left elbow pain
  • •Assess right elbow
  • •Assess left shoulder and wrist
  • •Assess Left elbow and contrast your findings with your assessment from the right elbow
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48
Q

Names of different movements

A

Active / Passive ROM

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49
Q

What to identify during the inspection of muscles?

A
  • Bilateral symmetry
  • Hypertrophy
  • Atrophy
  • Fasciculations
  • Spasms
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50
Q

Goniometer use

A

Use a gonimeter to determine ROM where there is an increased or decreased ROM

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51
Q

Active ROM and passive ROM would be equal in ______ joints

A

contralateral

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52
Q

How is muscle strength graded?

A

•Graded 0 (no voluntary contraction) to 5 (full muscle strength)

  • •Weakness may result from:
  • •Disuse atrophy
  • •Pain
  • •Fatigue
  • •Overstretching
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53
Q

Examination Muscle Strength

Grade

Level of Function

0 - No movement

1 - Trace movement

2 - Full passive range of motion

3 - Full range of motion against gravity, no resistance

4 - Full range of motion with resistance, though weak

5 - Full range of motion, full strength

A
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54
Q

What do you access for TMJ

A
  • Observation for abnormalities
  • Palpate
  • •Pain
  • •Crepitus, locking, and popping

•Assess ROM

  • •Open and close
  • •Lateral movement
  • •Protrusion and contraction
  • •Assess muscle strength
  • •Temporalis
  • •Masseter
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55
Q

What do you access for cervical spine?

Picture is muscle strength

A

•Inspect

  • •Head alignment
  • •Symmetry of muscles and skinfolds

•Palpate

  • •Tone
  • •Symmetry
  • •Tenderness
  • •Spasm

Picture is AROM

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56
Q

Cervical Spine

A. Normal

B. Scoliosis

C. Kyphosis

D. Lordosis

A
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57
Q

Scoliosis

Types of Scoliosis

A

·Congenital

·Neuromuscular

·Idiopathic

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58
Q

Thoraco-lumbar Scoliosis is more common in what population?

A

Thoraco-lumbar scoliosis is more common in peds and younger adults

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59
Q

Lumbar scoliosis is more common in what population?

A

Lumbar scoliosis more common in middle age and older adults

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60
Q

Flexion - Hyperextension

A

What is the Cervical Spine: Spurling Test

  • Passively extend and rotate the patient’s neck to the affected side. Slowly start applying axial pressure by pressing down on the top of the patient’s head
  • Radicular pain extending down the arm on the same side as the test is considered a positive test.
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61
Q

Thoracic Spine: Straight Leg Raise

Identify lumbar radiculopathy

Indicative of disc herniation, sciatica, nerve impingement

A
  • Have the patient lie supine. Lift one leg at a time to 90 degrees or as far as the patient can tolerate. Place your other hand on the knee to ensure full knee extension
  • The test is considered positive if there is pain between 30 and 70 degrees of hip flexion that radiates below the knee. To further confirm neurologic etiology, slightly lower the leg and dorsiflex the foot; this will often also reproduce the radicular symptoms.
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62
Q

Femoral Stretch Test

Used to detect inflammation on the nerve root at the L1, L2, L3, and sometimes L4 level

  • Have the patient lie prone and extend the hip
  • No pain is expected
  • The presence of pain on extension is a positive sign of nerve root irritation
A

Apley Scratch Test

The patient attempts to touch the opposite scapula

1) Testing abduction and external rotation
2) Testing adduction and internal rotation

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63
Q

What to INSPECT and PALPATE the Shoulders for:

A

INSPECT - Size, Symmetry, Contour, Dislocation or winging of the scapula

PALPATE - Joints, Muscles

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64
Q

Examination of the Shoulder

Acromioclavicular joint (Crossover)

Localized tenderness or pain suggests inflammation or arthritis

A

What does the drop arm test detect?

Detects tears in the rotator cuff, namely supraspinatus

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65
Q

Drop arm test

Have the patient abduct the shoulder to 90 degrees

Instruct pt to slowly lower arm

POSITIVE test if the arm drops around 90 deg abduction, indicating a tear in the supraspinatus

Abduction above the shoulder from 90-120’ reflects deltoid

If the patient is unable to perform this motion, the examiner can hold the humerus at 90 degrees of abduction and apply slight pressure to the distal forearm. If the patient’s arm falls to the side, this also indicates a rotator cuff dysfx.

A
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66
Q

Supraspinatus: Empty Can Test

Connects the top of the scapula to the humerus

Contraction allows the shoulder to abduct

Most commonly damaged rotator cuff muscles

Positive = pain and sometimes weakness indicative of Supraspinatus tear, impingement or nerve damage

A

Neer Test

  • identify supraspinatus impingement
  • While stabilizing the patient’s scapula, passively forward flex the arm while the arm is in the pronated position
  • Pain and apprehension are considered positive tests.
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67
Q

External rotator cuff test (test for infraspinatus and teres minor injuries)

  1. their shoulders, keeping both elbows bent at 90 degrees.
  2. Place your hands on the outside of their forearms.
  3. Direct them to push their arms outward (externally rotate) while you resist.

Interpretation: weakness and/or pain.

A

ROM for Elbows

  • Flexion: expect 160 degrees
  • Extension: expect 180 degrees
  • Pronation: expect 90 degrees
  • Supination: expect 90 degrees
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68
Q

Lateral Epicondylitis

A

Tennis Elbow

  • Lateral epicondylitis ( Tennis Elbow)
  • Gradual onset of pain outside ( lateral portion of the elbow)
  • At time radiate to forearms
  • Pain worsened with twisting or grasping movements

†Opening a jar, shaking hands

†Cozen’s test: With the elbow stabilized and the hand pronated and in a fist, have the patient extend their wrist against resistance.

Pain over the lateral epicondyle is considered a positive test.radial

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69
Q

Medial Epicondylitis

A

Golfers Elbow

  • Gradual onset of pain inside ( medial ) aspect of the elbow). AKA funny bone
  • Golfer elbow test:
  • with the elbow stabilized, have the patient supinate their hand and close their fist. Next, have the patient flex their wrist against resistance.
  • Pain over the medial epicondyle is considered a positive test.
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70
Q

Assess ROM for Hands and Wrists

A
  • Flexion of fingers: expect 90 degrees
  • Hyperextension of fingers: expect 30 degrees
  • Flexion of wrist: expect 90 degrees
  • Hyperextension of wrist: expect 70 degrees
  • Rotation of hand: expect radial motion of 20 degrees, ulnar motion of 55 degrees
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71
Q

Carpal Tunnel Syndrome

A

◦Pain or numbness of the thumb, index, middle finger especially at night

◦Hand weakness during tasks

◦Weak abduction of the thumb

Risk factors:

  • ◦Repetitive injury
  • ◦Work related
  • ◦Diabetes, hypothyroidism, and

Arthritis, pregnancy, High BMI,

Hypocalcemia

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72
Q

Tinel’s Sign

A

Tinel’s sign: tingling with tapping over the median nerve as it enters the carpal tunnel

Aching and numbness = positive sign

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73
Q

Phalen’s Sign

A

Phalen’s sign: numbness or tingling with pressing

backs of hands together in acute

flexion for 60 seconds

Numbness and tingling within 60 seconds = positive sign

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74
Q

De Quervain’s Syndrome

A
  • Gradually worsening pain along the radial aspect of the thumb and wrist painful condition due to stenosis of the tendon sheath in the 1st dorsal compartment of the radial aspect of the wrist.
  • Repetitive motions of the wrist and/or thumb result in microtrauma, metaplastic thickening of the tendons (EPB, APL), and narrowing of the surrounding tendon sheath.
  • Increased risk in women 30-50, pregnancy, AA, PMH with RA, repetitive activities (golf, fly fishing, racquet, rowing, bicycle, video game, text messages)
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75
Q

Finkelstein Test

A

De Quervain’s Syndrome

  • Finkelstein test identifies De Quervain’s syndrome
  • With the forearm stabilized, have the patient grasp their thumb in their fist, then perform ulnar deviation of the hand
  • Pain over the tendons is considered a positive test. Be sure to slowly deviate the hand, as this test, when positive, can be exquisitely painful.
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76
Q

Osteoarthritis

A

Has Heberden’s Nodes & Bouchards nodes that can also be present in RA and psoriatic arthritic

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77
Q

Heberden’s nodes

A

Osteoarthritis

Heberden’s nodes are hard or bony swellings that can develop in the distal interphalangeal joints (DIP)

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78
Q

Bouchard’s nodes

A

Osteoarthritis

Bouchard’s nodes are hard, bony outgrowths or gelatinous cysts on the proximal interphalangeal joints (PIP)

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79
Q

Rheumatoid Arthritis

A

Rheumatoid arthritis

It may begin any time in life.

Onset: Relatively rapid, over weeks to months

Joints are painful, swollen, and stiff.

It often affects small and large joints on both sides of the body (symmetrical), such as both hands, both wrists or elbows, or the balls of both feet.

**Morning stiffness usually lasts longer than 1 hour.

Frequent fatigue and a general feeling of being ill are present.

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80
Q

Dupuytren contracture.

A
  • •Dupuytren’s contracture is a progressive nodularity and flexion contracture of the palmar fascia and digital flexors in the hand
  • • slow onset over years and is usually seen in people over the age of 50. can lead to flexion contractures of the MCP and PIP joints
  • •Risk factors:

Tobacco, alcohol, and diabetes are all risk

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81
Q

Inspect hips for:

A

•Inspect

  • Symmetry
  • Size
  • Gluteal folds
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82
Q

ROM for HIPS

A
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83
Q

ROM Hip Knees

A
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84
Q

HIP: FABER test

A

Identifies hip flexor, sacroiliac, or hip intra-articular pathology. FABER stands for Flexion, ABduction, and External Rotation

With the patient supine, have them flex, abduct, and externally rotate the hip until the ankle rests upon the contralateral knee. Then, apply downward pressure, moving the knee closer to the table

Pain or decreased range of motion is considered a positive test.

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85
Q

HIP: FADIR TEST

A

FADIR TEST

The anterior impingement test or FADIR (Flexion ADDuction Internal Rotation) test is performed by flexing the hip to 90 degrees, adducting across the midline, and maximally internally rotating the hip

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86
Q

Ballottment

A

˜Medical sign which indicates increased fluid in the suprapatellar pouch over the patella at the knee joint. So test for knee effusion. To test ballottement the examiner would apply downward pressure towards the foot with one hand, while pushing the patella backwards against the femur with one finger of the opposite hand.

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87
Q

McMurray test

A

˜ Identifies meniscus pathology mostly tear to lateral or medial meniscus

˜Pain or clicking over the medial or lateral joint lines is considered a positive test.

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88
Q

ROM Feet/Ankle

A

Plantar Fasciitis / Flat Feet

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89
Q

Clubfoot

A
  • congenital condition where the forefoot is adducted, while the heel is in varus
  • Early treatment will include casting and bracing, with surgery becoming an option around month 3 or 4, though it can be delayed if necessary.
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90
Q

Gout

A
  • Gout is an inflammatory arthritis characterized by deposition of monosodium urate
  • crystals that accumulate in joints and soft tissues, resulting in acute and chronic arthritis, soft-tissue masses called toph

Classic presentation of acute gouty arthritis:

  • Intense pain and tenderness in the 1st metatarsophalangeal joint (podagra)
  • Can occur in the midtarsal, ankle, or knee joints
  • Joint may be swollen, warm, and erythematous.
  • Often awakens patients from sleep due to an intolerance to contact with clothing or bed sheets
  • There is a rapid onset of intense pain, often beginning in the early morning and progressing rapidly over 12 to 24 hours.
  • In the absence of treatment, flares can last up to 10 days.
  • Fever can be present.

Redness, swelling, decreased ROM and acute tenderness to the affected joint

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91
Q

Barlow Maneuver & Ortolani Maneuver

A

Hip Exam for Hip Dysplasia in the newborn

Done with the Ortolani maneuver (Abducted in a frog-leg position)

Barlow Maneuver Flex hip and knees to 90 degrees (Straight down)

Positive: Palpable and audible clunk as the head slips back into the socket

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92
Q

Older Adults you inspect for:

A

•Inspect

  • Dorsal kyphosis
  • Base of support broader (feet more widely spaced)
  • Reduction in total muscle mass
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93
Q

Osteoporosis

A
  • Osteoporosis
  • Disease in which a decrease in bone mass occurs because bone resorption is more rapid than bone deposition
  • Familial predisposition
  • More common in Caucasians and Asians than in African Americans and Hispanics
  • Symptoms: Asymptomatic
  • Spontaneous fracture
  • Thoracic kyphosis, poor balance, deconditioning
  • Loss of height
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94
Q

Osteopenia:

A

•midway point to osteoporosis; the bone density is lower than normal but not as severe

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95
Q

Central Nervous System

A

Main network of coordination and control for the body

Brain

Spinal Cord

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96
Q

Peripheral Nervous System

A

Carries information to and from the CNS

Cranial nerves

Spinal nerves

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97
Q

Autonomic nervous system

A

Coordinates and regulates the internal organs of the body

Two divisions that balance the impulses of each other are the:

Sympathetic division and Parasympathetic division

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98
Q

Sympathetic division of the nervous system does what?

A

•Sympathetic division: prods body to action during periods of physiologic and psychologic stress

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99
Q

Parasympathetic division of the nervous system does what?

A

•Parasympathetic division: functions in a complementary and counterbalancing manner to conserve body resources and day-to-day functions (e.g., digestion and eliminations)

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100
Q

The brain and spinal cord are protected by:

A
  • Skull and vertebrae
  • Meninges
  • Cerebrospinal fluid (CSF)
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101
Q

What do the three layers of the meninges do?

A

•Three layers of meninges produce and drain CSF

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102
Q

What does CSF do and where is it?

A

•CSF circulates between an interconnecting system of ventricles in the brain and around the brain and spinal cord, serving as a shock absorber

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103
Q

Three major units of the brain

A
  • Cerebrum
  • Cerebellum
  • Brainstem
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104
Q

What does the gray outer layer (cerebral cortex) house and is responsible for?

A

•Gray outer layer (cerebral cortex) houses the higher mental functions and is responsible for:

  • General movement
  • Visceral functions
  • Perception
  • Behavior
  • Integration of functions
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105
Q

Functions of the Brainstem

A
  • Pathway between the cerebral cortex and the spinal cord
  • Controls many involuntary functions
  • The nuclei of the 12 cranial nerves arise from these structures
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106
Q

How many peripheral nerves originate from the brain and what are their functions?

KNOW THE PICTURE

A
  • Twelve peripheral nerves that originate from brain
  • Functions
  • •Motor
  • •Sensory
  • •Parasympathetic
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107
Q

Gray matter on the spinal cord contains?

A

Nerve cell bodies

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108
Q

Spinal cord begins as a continuation of the…

A

medulla oblongata

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109
Q

Myelin coated white matter in the spinal cord contain….

A

Ascending and descending tracts

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110
Q

The spinal cord extends from the _______ to ______

and contains _____ and ______ pathways that exit and enter the cord via ______ and ______ nerve roots and ______ and ______ nerves

A

•The spinal cord

  • •Extends from brainstem (medulla) to L1-L2 vertebrae
  • •Contains motor and sensory pathways that exit and enter the cord via anterior and posterior nerve roots and spinal and peripheral nerves
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111
Q

5 segments of the spinal cord

A

•5 segments: cervical (C1-8), thoracic (T1-12), lumbar (L1-5), sacral (S1-5), coccygeal

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112
Q

Cauda equina

A

Cauda equina at L1-2, where nerve roots fan out like a horse’s tail

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113
Q

Spinal Nerves

A
  • Thirty-one pairs arise from the spinal cord
  • Exit at each intervertebral foramen
  • Sensory and motor fibers of each spinal nerve supply receive information in a specific body distribution called a dermatome
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114
Q

Within the spinal cord each spinal nerve separates into anterior and posterior roots

Motor or efferent fibers of the anterior root carry impulses…

Sensory or afferent fibers of the posterior root carry impulses…

A
  • Motor or efferent fibers of the anterior root carry impulses from the spinal cord to the muscles and glands of the body
  • Sensory or afferent fibers of the posterior root carry impulses from sensory receptors of the body to the spinal cord, and then on to the brain for interpretation by the cerebral sensory cortex
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115
Q

What are the primitive reflexes present in the newborn?

A

Moro (startle reflex), stepping, palmar and plantar grasp

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116
Q

At birth, the neurologic impulses are primarily handled by the

A

•At birth, the neurologic impulses are primarily handled by the brainstem and spinal cord

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117
Q

Motor maturation is in cephalocaudal direction

A

Cephalocaudal (head to toe direction)

  • Head and neck
  • Trunk
  • Extremities
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118
Q

Older adults and the CNS

A
  • The number of cerebral neurons decreases with aging, but this is not necessarily associated with deteriorating mental function
  • Vast number of reserve neurons inhibits the appearance of clinical signs
  • Velocity of nerve impulse conduction declines
  • •Slowed response time
  • •Diminished touch and pain perception
  • •Diminished functions of smell, taste and vision

•Normal aging changes increase risk for abnormal findings

  • •Unsteady gait, increase risk of fall
  • •Decrease Range of motion
  • •Diminished appetite
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119
Q

Vertigo

A

Vertigo

Chief complaint - Spinning or sensation of self motion

Triggering event - Acute asymmetry of vestibular system. Turning over in bed. Looking up to self. Moving the head

Associated symptoms and important historical features - CNS signs or symptoms: dysarthria, headache, diplopia, ataxia, neck pain. Auditory symptoms: hearing loss, tinnitus. Ataxic duration. Nausea, vomiting, unbalanced, oscillation

Key physical exam findings

  • Cranial nerve exam
  • Gait
  • Finger to nose exam
  • HINTS plus exam
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120
Q

Near Syncope

A

Chief complaint - Sense of impending loss of consciousness

Triggering event - Orthostatic hypotension upon standing. Reduced cerebral blood flow, decrease cardiac output

Associated symptoms and important historical features -

  • Tunnel vision
  • Palpitation
  • Perspiration, pallor
  • “Almost blacking out” or “almost fainting”

Key physical exam findings

  • Orthostatic Blood pressure and pulse
  • Cardiac exam for murmur, JVD or S3
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121
Q

Dysequilibrium

A

Chief complaint - Unstable while seated, standing or walking

Triggering event - Dizziness while Walking

Associated symptoms and important historical features -

  • Multi sensory deficit, periphral
  • Neuropathy
  • Visual problem
  • medication

Key physical exam findings

  • Gait
  • Romberg
  • Position sense
  • Sensation
  • Cranial nerve exam
  • Finger to nose exam
122
Q

Light Headedness

A

Chief complaint - Floating, vague, unclear sensation of falling

Triggering event - Stress, anxiety, depression, or panic disorder

Associated symptoms and important historical features - Multiple somatic complaints. Feeling down or hopeless

Key physical exam findings

123
Q

Dizziness red flags

A
  • Abnormal vital signs
  • Hemodynamically unstable
  • Confusion/Impaired mental status
  • Associated pain
  • Neurological symptoms
  • New headache, Diplopia, dysarthria, dysphasia, drop attack, unilateral weakness
  • Cardiovascular symptoms (chest pain, dyspnea, syncope)
  • vomiting
  • Fever
  • Ataxia (abnormal movement/gait)

CAN THERE BE A BLEED SOMEWHERE

124
Q

Practical Approach to Dizziness

TITRATE

TIming TRiggering Target Examination

A

Dizziness Algorithm

Vertigo is dizzyness within

Dizzyness is room spinning

KNOW THIS ALGORHYTHM

125
Q

HINTS Exam

A

Tremor Algorithm

126
Q

Dix-hallpike maneuver

A

Determines vertigo and nystagmus

  • Results
  • Positive:
  • “down” side produces nystagmus and trigger dizziness and is the side causing the positional vertigo
  • If the right side is being tested (in the “down” position), the eye will rotate in a counterclockwise manner during the rapid phase of nystagmus, with a minor up-beating vertical (toward the forehead) component
  • If the left side is being tested, the results are similar except the eye rotates clockwise
  • Negative:
  • No nystagmus is noted
127
Q

Action Tremor

A

Occurs with voluntary contraction of muscle

Includes postural, isometric and kinetic tremors

128
Q

Postural Action Tremor

A

Occurs with any form of voluntary movement

Includes essential physiologic, cerebellar, dystonic and drug-induced tremors

129
Q

Kinetic Action Tremor

A

Occurs with any form of voluntary movement

Includes classic essential, cerebellar, dystonic, and drug-induced tremors

130
Q

Intention Action Tremor

A

Subtype of kinetic tremor amplified as the target is reached

Presence of this type of tremor implies that there is a disturbance of the cerebellum or its pathways

131
Q

Rest Tremor

A

Occurs in a body part that is relaxed and completely supported against gravity

Most commonly caused by parkinsonism, but may also occur in severe essential tremors

132
Q

Olfactory (I)

A

SENSORY

Brain Pathway: Mucous membrane of nose to olfactory bulbs

Olfactory receptors for sense of smell

133
Q

Optic II

A

SENSORY

Brain Pathway: II Retina -> optic nerve -> thalamus -> occipital lobe

Retina for sense of sight

134
Q

Oculomotor III

A

MOTOR

Brain Pathway: Midbrain -> eye and eyelid

Eye muscles (including eyelids and lens); pupil (parasympathetic division)

135
Q

Trochlear IV

A

MOTOR

Brain Pathway: Midbrain -> eye

Eye muscles

136
Q

Trigeminal V

A

MIXED - SENSORY & MOTOR

Brain Pathway: V

Sensory: Teeth, eye, skin, tongue -> pons

Motor: Pons -> jaw muscles

Transmits nerve impulses to the teeth, eyes, skin, and tongue

137
Q

Abducens (VI)

A

MOTOR

Brain Pathway: VI: Pons -> eye

Eye muscles

138
Q

Facial (VII)

A

MIXED - SENSORY & MOTOR

Brain Pathway: VII

Sensory: Tongue -> pons. Taste buds on the anterior tongue.

Motor: Pons -> facial muscles, Salivary glands, tear glands

139
Q

Vestibulocochlear (VIII)

aka Acoustic

A

SENSORY

Brain Pathway: Inner ear -> pons and medulla

Inner ear for sense of balance and hearing

140
Q

Glossopharyngeal (IX)

A

MIXED SENSORY & MOTOR

Brain Pathway: (IX) Sensory: Tongue, throat -> pons.

Motor: Pons -> Salvary gland, Throat muscles. Pharyngeal muscles (swallowing), salivary glands

141
Q

Vagus (X)

A

X - MIXED - SENSORY - MOTOR

Brain Pathway: X Sensory: Eardrum, ear canal, throat, heart, lungs, abdominal organs -> medulla

Internal organs, external ear canal, ear drum, and back of throat

Motor: Medulla -> throat and larynx , heart, lungs, abdominal organs

142
Q

Spinal Accessory (XI)

A

XI - Motor

Brain pathway: Medulla -> throat and larynx, heart, lungs, abdominal organs

Internal organs (parasympathetic division), throat muscles (somatic motor division)

143
Q

Hypoglossal (XII)

A

MOTOR XII

Brain Pathway: Medulla -> tongue muscles

Tongue muscles

144
Q

Optic (CN II) Sensory and visual acuity

on FINAL

A

Test for visual acuity

Test for visual fields

Sensory component of the pupillary reflex

ONLY SENSORY

145
Q

Visual Acuity : Central Vision

To examine CN II and ocular fx

A

•Position yourself in front of the patient.
Test the patient’s visual acuity, each eye separately covering one at a time.

•Snellen’s chart. Visual acuity is recorded as a fraction. The numerator indicates the distance (in feet) from the chart which the subject can read the line.

The denominator indicates the distance at which a normal eye can read the line. Normal vision is 20/20.

146
Q

How to perform Rosembaum test:

A

Rosembaum: pocket screener is used at the bedside. Hold the pocket screener at a distance of 12-14 inches. At this distance the letters are equivalent to those on Snellen’s chart.

147
Q

Vision field by CONFRONTATION

A

•By confrontation

  • •Position yourself in front of the patient.
  • •The nose normally cuts off the medial field of vision.
  • •Hence, compare the patient’s right eye to your left eye and vice versa.
  • •Instruct the patient to look straight at you and not to move their eyes.
  • •Compare your field of vision with the subject’s.
  • •Bring your finger from the right field of vision until it is recognized.
  • •Test one quadrant at a time.
  • •Wiggle your fingers to see whether the patient can recognize the movement.
  • •Some like to have the patient count fingers, i.e., 1, 2 or 5.
  • •Test all four quadrants in a similar fashion.
  • •When abnormality is detected , would require automated methods of testing in the lab
148
Q

Pupils: Reaction to light

CN II, III, and mid-brain connections

A
  • Have the patient look at a distant object
  • Look at size, shape and symmetry of pupils.
  • Shine a light into each eye and observe constriction of pupil.
  • Flash a light on one pupil and watch it contract briskly.
  • Flash the light again and watch the opposite pupil constrict (consensual reflex).
  • Repeat this procedure on the opposite eye.
  • Normal:
  • Pupil size is 3-5 mm in diameter.
  • They react briskly to light.
  • Both pupils constrict consensually.
149
Q

Extraocular Eye Movements

CN III, IV, VI

A
  • •Note the alignment of the eyes at rest.
  • •Ductions: Movement of one eye at a time
  • •Versions: Both eye movement
  • •Have the patient follow an object into each of the nine cardinal fields of gaze.
  • •Note that both eyes move together into each field.
  • •Eye movements should be smooth and without jerking.
  • •Eyelids should be gently lifted up by the examiner’s fingers when testing downward gaze.
  • •Jerky, oscillatory eye movements (nystagmus) may be abnormal, especially if sustained or asymmetrical.
150
Q

Ductions

A

Movement of one eye at a time

151
Q

Versions

A

Both eye movement

152
Q

Trigeminal

CN V

Corneal reflex

A

•Corneal reflex: patient looks up and away.

  • Touch cotton wool to other side.
  • Look for blink in both eyes, ask if can sense it.
  • Repeat other side tests V sensory, VII moto

•Facial sensation: sterile sharp item on forehead, cheek, jaw.

  • Repeat with dull object. Ask to report sharp or dull.
  • If abnormal, then temperature [heated/ water-cooled tuning fork], light touch [cotton].

•Motor: pt opens mouth, clenches teeth.

  • Palpate temporal, masseter muscles as they clench.
153
Q

Motor Function: Facial muscle

CN VII

A

Raise eyebrows

Tightly close eyes

Puff out cheeks

Show teeth

154
Q

Bell’s Palsy

Facial asymmetry

A

Inability to close eyelid

Drooping of the mouth

Facial nerve

Absence of NL fold

Absence of other neurological deficits such s/s of stroke

155
Q

Causes of Bell’s Palsy

A

Often linked to exposure to a viral infection. Same viruses that cause;

cold sores and genital herpes (herpes simplex)

Chickenpox and shingles (herpes zoster)

Mononucleosis (Epstein-Barr)

Cytomegalovirus infections

Respiratory illnesses (Adenovirus)

German measles (Rubella)

Mumps (mumps virus)

Flu (Influenza B)

Hand foot and mouth disease (coxsackievirus)

156
Q

CN VIII

HEARING

A
157
Q

GLOSSOPHARYNGEAL

CN IX

MIXED

A

Taste & Swallowing

Test tongue for sour and bitter

Test gag reflex and swallow

158
Q

VAGUS

CN X

A

MIXED

Swallowing & Speech

  • Inspect palate and uvula for symmetry
  • Inspect for swallowing difficulty
  • Evaluate guttural speech sounds
159
Q

CN XI

Trapezius and Sternocleidomastoid muscles

A
  • Have patient shrug shoulder against resistance and evaluate strength of Trapezius muscle.
  • Have patient turn head to one side against resistance and evaluate strength and observe contracting sternomastoid muscle
160
Q

CN XII

A

Tongue Movement

This nerve tests the bulk and power of the tongue.

Tongue will deviate toward the lesion of the brain

161
Q

How to document CN assessment

A

CN II - XII grossly intact

162
Q

CN I

A

Olfactory

Smell

Odor recognition

163
Q

CN II

A

Optic

Visual acuity

Visual fields

164
Q

CN III

A

Oculomotor

Raise eyebrows

Extraocular eye movements

165
Q

CN IV

A

Trochlear

Eye movement - inward and downward

166
Q

CN V

A

Trigeminal

Chewing

Clenching teeth

Sensations on forehead

167
Q

CN VI

A

Abducens

Lateral eye movements

168
Q

CN VII

A

Facial

Facial expressions

Taste - anterior 2/3 of tongue

Secretion tears and saliva

169
Q

CN VIII

A

Acoustic

Hearing

Equilibrium

170
Q

CN IX

A

Glossopharyngeal

Swallowing

Gag reflex

Taste - posterior third of the tongue

Salivary gland secretion

171
Q

CN X

A

Vagus

Speech phonation

Swallowing

Sensation behind ear

Gag reflex

172
Q

XI

A

Spinal Accessory

Turn head

Shrug shoulders

173
Q

XIII

A

Hypoglossal

Tongue movement

174
Q

The Romberg Test

A

Patient stands with feet together and eyes open, then with the eyes closed for 30 - 60 seconds without support

Loss of balance when eyes closed is a positive test

175
Q

The pronator drift

A
  • patient to stand for 20 to 30 seconds with eyes closed and both arms straight forward with palms up
  • clinician taps the arms briskly downward. The arms normally return smoothly to the horizontal position,
  • loss of position strength, arms will drift sideward or upward, which is a positive test for pronator drift
176
Q

How to access a patients gait

A

•Gait – assess gait as patient:

  • Walks across room
  • Walks heel-to-toe
  • Walks on toes then heels
  • Hops in place
177
Q

Heel to toe coordination testing

A

•Assess proprioceptive system including cerebellar function

178
Q

How to test for Sensory Function

A

•Superficial/light touch

  • Cotton wisp or fingertip

•Superficial pain

  • Broken tongue blade or the point and hub of a sterile needle

•Temperature

  • Tested only when superficial pain sensation is not intact

•Vibration

  • Tuning fork (lower Hz)

•Proprioception sensory function

  • Position of joints
    • Raise or lower
179
Q

Monofilament test

A
  • Sensory test to evaluate diabetic and peripheral neuropathy
  • Testing with a 5.07 monofilament should be done on several sites
  • the patient’s eyes closed, the clinician places the monofilament on several sites of the plantar surface of each foot and one side of the dorsal surface of the foot in a random pattern
  • pressure for 1.5 seconds to each site
  • Testing is positive if the patient cannot feel the monofilament indicative of peripheral neuropathy
180
Q

Cortical Sensory Function

A
  • Test cognitive ability to interpret sensations
  • Inability to perform these tests should make you suspect a lesion in:
  • •Sensory cortex
  • •Posterior columns of the spinal cord

•The primary sensory functions must be intact to perform cortical sensory function

  • •Always check if primary sensory functions are intact, first
181
Q

Stereognosis

(Cortical Sensory Function)

A

Familiar object (key, coin)

182
Q

Graphesthesia

A

Ability to recognize numbers, symbol

Letter traced on the palm

183
Q

Tactile Agnosia

A

An inability to recognize objects by touch, suggests a parietal lobe lesion

184
Q

Cortical Sensory Function

A

Eyes closed

•Point location

  • •Touch an area on the patient’s skin and withdraw the stimulus
  • •Ask the patient to point to the location you lightly touched
  • •Prefered test by provider (quick)

•Two-point discrimination

  • •Distance at which the patient can no longer distinguish two points
  • •Varies with body parts

•Extinction phenomenon

  • •Simultaneously touch two areas on each side of the body
  • •Similar sensations should be felt bilaterally
  • •Patient should be able to discriminate the number of touches
185
Q

Deep Tendon Reflexes

General Principles

A
  • Select a properly weighted hammer
  • Encourage the patient to relax;
  • Hold the reflex hammer loosely
  • brisk direct movement; use the minimum force needed to obtain a response
  • Use reinforcement when needed
  • Grade the response 0-4+
186
Q

List the Superficial Reflexes

A

Plantar reflex

Abdomen reflexes

Cremaster reflex

Anal wink

187
Q

How to perform the Plantar Reflex

A
  • Stroke the lateral side of the foot from the heel to the ball and then curve across the ball of the foot to the medial side
  • Patient should have plantarflexion of all toes
  • Babinski sign is present when there is dorsiflexion of the great toe
  • Indicates pyramidal tract disease
188
Q

Location of tendons for evaluation of deep tendon reflexes

A

A, Biceps. B, Brachioradial. C, Triceps. D, Patellar. E, Achilles. F, Evaluation of ankle clonus.

189
Q

How do you perform a Biceps - deep tendon reflex

A

1- Have the patient’s elbow at about a 90° angle of flexion with the arm slightly bent down as shown in figure 2-6.

2- Grasp the elbow with your left hand so the fingers are behind the elbow and your abductee thumb presses the biceps brachial tendon.

3- Strike your thumb a series of blows with the rubber hammer, varying your thumb pressure with each blow until the most satisfactory response is obtained.

4- Normal reflex is elbow flexion (bending)

190
Q

How do you perform a Triceps - deep tendon reflex

A
  • Grasp the patient’s wrist with your left hand and pull his arm across his chest so the elbow is flexed about 90° and the forearm is partially bent down.
  • Tap the triceps brachial tendon directly above the olecranon process. The normal response is elbow extension.
191
Q

How to perform Brachioradialis Reflex

A
  • Strike the brachioradialis tendon on the lateral side of the forearm
  • Apply your finger over the area and strike the hammer on your finger
  • Mild supination of the hand, wrist extension and flexion of the elbow
192
Q

How to perform the Achilles reflex : ankle jerk

A
  • Tap the Achilles tendon and the foot should extend from the contraction of the gastrocnemius and soleus muscles responding to that tap. Perform the reflex test in this manner:
  • Have the patient sit on a table or bed so that his legs dangle.
  • With your left hand, grasp the patient’s foot and pull it in dorsiflexion (upward). Find the degree of stretching upward of the Achilles tendon that produces the optimal response.
  • Tap the tendon directly.
  • Normal response is contraction of the gastrocnemius and plantar flexion of the foot.
193
Q

Deep tendon reflexed with cord levels for each response to help localize any abnormalities

A
  • Biceps reflex (C5-6)
  • Brachioradial (C5-6)
  • Triceps reflex (C6-8)
  • Supinator or brachioradialis (C5-6)
  • Patellar reflex (L2-4) (May need interlocking hands to distract)
  • Ankle reflex (primarily S1-and L5) Please correct
  • Clonus, a hyperactive response required for assigning a reflex grade of 4, usually elicited at the ankle
  • Superficial reflex
  • Cremasteric (T12; L1-2)
  • Plantar (L5; S1-2)
194
Q

Meningeal Sign

A

Neck mobility

Brudzinski’s sign

Kernig’s sign

195
Q

Brudzinski sign

A

•Severe neck stiffness causes a patient’s hips and knees to flex when the neck is flexed.

196
Q

Kernig’s sign

A

•Severe stiffness of the hamstrings and inability to straighten the leg when the hip is flexed to 90 degrees

197
Q

Decorticate Posturing

A

Legs and feet extended with plantar flexion and arms rotated and flexed on chest.

Decorticate posture may progress to decerebrate posture, or the two may alternate. The posturing may occur on one or both sides of the body.

198
Q

Decerebrate posturing

A

Arms stiffly extended and hands turned outward and flexed, leg also extended with plantar flexion

Decorticate posture may progress to decerebrate posture, or the two may alternate. The posturing may occur on one or both sides of the body.

199
Q

What are Static disorders of the central and peripheral nervous system?

A

•Static problems develop at any age and do not get better or worse (e.g., nerve deafness and some trauma)

200
Q

What are Degenerative disorders of the central and peripheral nervous system?

A

•Degenerative problems occur when function is lost and it progressively worsens

201
Q

What is Multiple Sclerosis

A
  • Multiple sclerosis
  • Progressive autoimmune disorder characterized by a combination of inflammation and degeneration of the myelin of the brain’s white matter leading to decreased brain mass and obstructed transmission of nerve impulses
202
Q

How does MS progress?

A

•Gradual, but unpredictable, progression, with or without remissions

203
Q

What are the physical side effects of MS

A

•Physical:

  • Weakness
  • Gait disturbance
  • Foot drop
  • Hyperesthesia or paresthesia
  • Cerebellar dysarthria (scanning speech)
  • Spasticity (especially in lower extremities)
    • Positive clonus, Babinski.
204
Q

What are Seizure disorders and what are they caused by?

A

•Episodic abnormal electrical discharges (excessive concurrent firing) of cerebral neurons may be caused by:

  • CNS disorder
  • CNS structural defect
  • Disorder that affects functioning of the CNS

•Examples include brain injury, toxins, stroke, brain tumor, or hypoxic syndromes

205
Q

What is a stroke and what are the two types of stroke?

A
  • Stroke (brain attack or cerebrovascular accident)
  • Sudden interruption of blood supply to a part of the brain or the rupture of a blood vessel, spilling blood into spaces around brain cells
  • Ischemic
  • Hemorrhagic
206
Q

What is Myasthenia Gravis

A

•Myasthenia gravis is a Peripheral Nervous System disease

  • •Autoimmune disorder of neuromuscular transmission
  • •Usually proximal to distal progression
207
Q

What is the hallmark of MG

A

Fatigability

208
Q

What are the physical side effect of MG?

A
  • Fluctuating weakness, often subtle, that worsens during the day and after prolonged use of affected muscles, may improve with rest
  • Early symptoms are transient with asymptomatic periods lasting days or weeks.
  • >50% of patients present with ocular symptoms (ptosis and/or diplopia). Eventually, 90% of patients with MG develop ocular symptoms.
  • Ptosis might be unilateral, bilateral, or shifting from eye to eye.
209
Q

What is Guillain-Barre Syndrome

A

•Autoimmune-mediated destruction of peripheral nerve myelin sheaths and inflammation of nerve roots

210
Q

What are the characteristics of Guillain-Barre syndrome

A
  • Occurs following a nonspecific gastrointestinal or upper respiratory infection 1 to 3 weeks earlier or following an immunization
  • Distal to proximal progression
  • Typical features are distal sensory changes followed by progressive motor weakness and areflexia.
211
Q

Physical characteristics of Guillain Barre syndrome

A
  • unsteady gait which may be due to sensory ataxia, facial weakness, diplopia, leg or back pain, or sensory changes in the extremities.
  • Paresthesia and pain typically occur in a stocking/glove distribution, frequently early in the course.
  • Most patients first note leg weakness or gait instability that progresses over days to weeks. 60% are unable to walk at the peak of symptoms.
  • Characteristic findings include muscular weakness and sensory changes, most often symmetric with distal greater than proximal involvement
212
Q

What is Trigeminal neuralgia (tic douloureux)

A

•Recurrent paroxysmal sharp pain that radiates into one or more branches of the fifth cranial nerve

213
Q

Peripheral neuropathy

A

•Disorder of the peripheral nervous system that results in motor and sensory loss in the distribution of one or more nerves

  • Diabetes mellitus
  • B12 deficiency
  • Lyme disease
  • HIV infection
214
Q

What is Cerebral Palsy?

A

•Permanent non-progressive (adult stage) disorder of movement and posture development

215
Q

Physical presentation of CP

A
  • Assess for more than one type of neurologic impairment:
  • Spasticity: increased tone/reflexes/clonus
  • Dyskinesia: abnormal movements
  • Hypotonia: decreased tone
  • Ataxia: abnormal balance/coordination
216
Q

A clinical diagnosis of CP includes

A
  • Delayed motor milestones
  • Abnormal tone
  • Abnormal neurologic exam suggesting a cerebral etiology for motor dysfunction
  • Absence of regression (not losing function)
  • Absence of underlying syndromes or alternative explanation for etiology
217
Q

What is Myelomeningocele (spina-bifida)

A

•Congenital defect of one or more vertebrae (commonly the lumbar or sacral) that permits a meningeal sac filled with a portion of the spinal cord to protrude

218
Q

How do you best prevent Spina Bifida

A
  • Best prevented by taking a daily dose of folic acid
  • As soon as you suspect pregnancy before confirming it, please, please start the mother on folic acid 400 mg po daily
219
Q

Shaken baby syndrome

A
  • Severe form of child abuse resulting from the violent shaking of infants under 1 year of age
  • Stretching and tearing of nerve tissue and blood vessels causes brain damage and a subdural hematoma
  • Spinal cord may also be damaged
220
Q

What are the characteristics of Parkinson disease

A
  • Slowly progressive, degenerative neurologic disorder
  • Deficiency of the dopamine neurotransmitter results in poor communication between parts of the brain that coordinate and control movement and balance
221
Q

What is the first sign of Parkinsons disease

A

•First signs usually a mild resting tremor unilateral presentation

222
Q

A complete neurological assessment includes

A

A complete neurological assessment consists of :

  • Cranial nerves
  • Proprioception (feeling and self in space and balance) and cerebellar function
  • Sensory function
  • Reflex function
223
Q

CN II

A

No motor component

See the light

224
Q

CN III

A

Motor component

Pupil constricts

225
Q

Trigeminal neuralgia

aka

A

Tic Douloureux

A condition affecting the largest nerve in the face that provides sensation. Only sensory not motor. Described as the worst pain known to mankind.

226
Q

What is a tell-tell sign of Bell’s Palsy and what precedes it?

A

Loss of NL fold and a respiratory illness precedes it

227
Q

CN IX

A

The fact they can feel the stick in the back of the throat and the raising of the uvula

228
Q

CNX

A

Swallowing

229
Q

Proproception

A

Sense of self in space and gait.

230
Q

•Abstract thinking develops:

A
  • Ability to develop theories
  • Ability to use logical reasoning
  • Ability to make future plans
  • Ability to use generalizations
  • Ability to consider risks and possibilities
231
Q

Judgment begins to develop with

A

education, intelligence, and experience.

232
Q

HEADSS assessment

A

HEADSS assessment

(Home, Education/Employment, Activities, Drugs, Sexuality, Suicide)

233
Q

Cognitive function should be intact in the healthy older adult, but declines in cognitive abilities occur in some older adults after

A

60 or 70 years of age.

234
Q

Speed of information processing and psychomotor speed begin declining at a modest rate after

A

•30 years of age

235
Q

Verbal skills and general knowledge continue to increase into the_____and often remain stable into the _____

A

•Verbal skills and general knowledge continue to increase into the 60s and often remain stable into the 80s.

236
Q

In older adults recent memory is believed to deteriorate before

A

remote memory

237
Q
  • Cognitive declines in executive functioning often preceded memory loss in a recent study of highly functioning elderly women
  • Plan and develop strategies
  • Organize, concentrate, and remember details
  • Manage activities
  • The cognitive decline leading to dementia may occur over 20 to 30 years, and it may begin as early as 45 years of age in some persons.
A

Mnemonic for Depression SIGECAPS (associated factors to depression: oldcaArts

  • S sleep disorders
  • I interest (anhedonia – no interest)
  • G guilt (worthlessness, regret, hopelessness)
  • E energy deficit
  • C concentration
  • A appetite
  • P psychomotor retardation or agitation(irritability)
  • S suicidality
238
Q

What are key questions and considerations when assessing the mental status of a patient

A
  • Conducted within context of age, developmental level, and cultural norms
  • Appearance: Affect, posture, hygiene and grooming, body habitus
  • Behavior: Verbal/nonverbal expressions of pain, anxiety, emotions, interactions, activity level, body movements and mobility
  • Cognition: Oriented to time, person, and place, attention and concentration, pattern and pace of speech, judgment, memory, mood
239
Q

What 3 things are identified when assessing for DTS or DTO?

A
  • Homicidal ideation (HI)
  • Suicidal ideation (SI)
  • Identify protective factors

If there is a DD of mental health you have to ask about suicidal ideations

240
Q
A
241
Q

Mneumonic for Depression SIGECAPS

assoc factors to depression

A
  • S sleep disorders
  • I interest (anhedonia – no interest)
  • G guilt (worthlessness, regret, hopelessness)
  • E energy deficit
  • C concentration
  • A appetite
  • P psychomotor retardation or agitation(irritability)
  • S suicidality
  • Must have experienced at least five of the symptoms for the previous two weeks to be diagnosed with a MDD!!!!
242
Q

PHQ2

LOOKS AT SX IN THE PAST 2 WEEKS

START LOOKING AT INTERVENTIONS AT A SCORE OF 10

A

Assess mental health during the general survey or if there is a past medical history

243
Q

What are some Differential diagnoses for someone presenting with depression

A
  • Mental health conditions:
  • Depression
  • Depressed phase of bipolar disorder—inquire if prior mania, family or personal history of bipolar disorder, prior agitation, or excitement with antidepressant medication.
  • Adjustment disorder with depressed mood
  • Substance abuse-related mood disorders
  • Medical comorbidity: adrenal diseases, anemia, hypothyroidism, diabetes, hypercalcemia, liver or renal failure, malignancy, sleep disorders, chronic fatigue syndrome, fibromyalgia, lupus
  • Neurologic or cognitive disorders such as neurodegenerative CNS disease, dementia, or delirium
  • Deficiencies: vitamin B3, Vitamin D, vitamin B12, or folate
244
Q

What is SAFE-T

Suicide Assessment Five-step Evaluation and Triage

A
  1. Identify risk factors
  2. Identify protective factors
  3. Conduct suicide inquiry
  4. Determine risk level/intervention
  5. Document
245
Q

What are some suicide risk factors?

A

Psychic pain/anxiety

Psychiatric diagnosis; Prior Suicide attempt

Agitation; Comorbidity; Firearm access;

Hopelessness

246
Q

HPI: Anxiety GAD - 7

SCORE OF 10 REQUIRE INTERVENTION

A
247
Q

Name two screening tests to access cognition

A

Mini-Mental State Examination (MMSE) - most studied

Mini-Cog - three unrelated words, clock face

248
Q

Mini-Mental State Examination MMSE

A

Anyone over 65 should have one

A score up to 24 is NORMAL

Score of 20 is MILD

249
Q

Mini-Cog Screening

A

1- Get your patient’s attention and have them repeat 3 unrelated words to you. You may repeat words up to 3 times to make sure patient has register each one.

Leader, season, table.

2- Ask the patient to draw a clock face with all the numbers on it then and set the time at 10 past 11. You may repeat instructions as needed.

If patient cannot complete the clock in 3 minutes (score zero) and move to the next step

2 points if correct, with all numbers inside the circle, right sequence and right time. And Zero point if incorrect

3- Recall 3 words.

1 point for each word correctly recalled

Interpretation:

0-2 = positive screen

3-5 = negative screen but does not rule out completely cognitive impairment

A score of 3 or less: patient needs to be evaluated further.

250
Q

Catatonia:

A

Catatonia: group of symptoms that usually involve a lack of movement and communication, and also can include agitation, confusion, and restlessness. Often present in schizophrenic patients – talking to a statue then super agitated

251
Q

Akathisia

A

Akathisia (Greek “not to sit”) is an extrapyramidal movement disorder consisting of difficulty in staying still and a subjective sense of restlessness.

252
Q

Pressured speech

A

Pressured speech: characterized by rapid, compulsive talking, is a classic symptom of hypomanic and manic episodes in people with bipolar.

253
Q

Apathetic:

A

Apathetic:

  • stop caring about everyday tasks, hobbies, or personal interests
  • struggle to show interest and enthusiasm in others
  • feel indifferent to spending time with others
  • experience very little emotion or changes in mood
254
Q

Elated mood

A

Elated mood: state of heightened joy, exaggerated optimism, and restless excitement. Indicative: drug induced, schizophrenia, psychosis, mania.

255
Q

Labile mood:

A

Labile mood: characterized by sudden, rapid changes in mood not congruent to the stimuli.

256
Q

What algorithm do you reference for Suicidal Ideations?

A

SAFE-T

257
Q

Concrete thinking:

A

Concrete thinking: “cognition that reflects experience, rather than abstraction, typical of those who are unable to generalize.” AKA literal thinking

258
Q

Circumstantial thought:

A

Circumstantial thought: the use of many words where fewer would do AKA Circumstantiality: speech characterized by indirection
and delay due to the patient’s excessive use of details
that have no connection to the point

259
Q

Tangentiality:

A

Tangentiality: phenomenon in which a person constantly digresses to random, irrelevant ideas and topics, never answering the original questions.

260
Q

Loose associations AKA Derailment:

A

Loose associations AKA Derailment: a person shifts topics with no apparent relation between the topics, The frame of reference often changes from one sentence to the next. Thought derailment is a symptom of schizophrenia

261
Q

Echolalia

A

Echolalia: repeat noises and words they hear instead of expressing their thoughts. For example, instead of answering a question, they may repeat the question.

262
Q

Flight of ideas

A

Flight of ideas: similar to derailment but much faster in speed, close to manic. “people to speak rapidly and quickly shift between loosely connected ideas when speaking. Speech is pressured, quick, at time incoherent, speak so fast they may slured their speech, but for them, they make complete sense. Schizophrenia.

263
Q

Perseveration

A

Perseveration: persistent repetition of words or ideas even when another person attempts to change the topic. Talking about a grievance over and over, and won’t stop even when provider wish to change the subject. common symptom of early Alzheimer’s disease

264
Q

Clangassociation

A

Clangassociation : speech in which word choice is governed by word sound rather than meaning; word choice may show rhyming or punning associations. Example: He rained the train brain strain gain the crane.”. Bipolar, schizophrenia,

265
Q

Blocking

A

Blocking: interruption of speech while ostensibly in pursuit of a goal

266
Q

Word salad:

A

•Word salad: Incoherence (word salad, schizaphasia): severe lack of speech cohesion at the basic level of syntax and/or semantics within sentences. Advanced Schizophrenia. Example” Run desk making dinner sunglasses menu”

267
Q

Magical thinking/delusion:

A

Magical thinking/delusion: similar: the belief that one’s ideas, thoughts, actions, words, or use of symbols can influence the course of events in the material world. Magical thinking presumes a causal link between one’s inner, personal experience and the external physical world.

268
Q

Poverty of speech:

A

Poverty of speech: a common symptom of schizophrenia, and may co-occur with poverty of content – assoc depression

269
Q

Neologism

A

Neologism: the creation of new “words”

270
Q

Illusion

A

Illusion: misinterpretation of a correct sensory input. For example, a child who perceives tree branches at night as if they are monsters.

271
Q

Impulse control disorders:

A

Impulse control disorders: condition in which a person has trouble controlling emotions or behaviors. Often, the behaviors violate the rights of others or conflict with societal norms and the law.

272
Q

Judgement

A

Judgement: The ability to make considered decisions or come to sensible conclusions. “what would you do if you saw a fire in a movie theater?”

273
Q

Insights

A

Insights: the capacity to gain an accurate and deep intuitive understanding of a person, situation, event.

274
Q

Concussion

A

•Rotational forces cause a transient disruption in the reticular neurons that maintain alertness

  • Sports injuries
  • Motor vehicle accidents
  • Falls
275
Q

Delirium

A
  • Impaired cognition, consciousness, mood, and behavioral dysfunction of acute onset
  • Risk factors
  • Serious illness
  • Injury
  • Preexisting cognitive decline

Fluctuating mental health

276
Q

•Delirium tremens

A

•Brain’s response to withdrawal from alcohol consumed in large quantities over time•

Delirium tremens signs include agitation, confusion, combativeness, panic, seizures, hallucinations, and illusions

277
Q

•Depression

A
  • Common psychiatric disorder associated with a neurochemical imbalance
  • Symptoms from mild to major depressive disorder are characterized by feelings of helplessness and hopelessness and recurrent suicidal thoughts
278
Q

Mania

A
  • Persistently elevated, expansive, or irritable mood lasting longer than 1 week, one phase of the bipolar disorder
  • Associated with a neurochemical imbalance, an increased level of monoamines
279
Q

•Anxiety disorder

A

•Group of disorders with such marked anxiety or fear that it causes significant interference with personal, social, and occupational functioning

Associated with abnormalities in the norepinephrine and serotonin systems

280
Q

•Schizophrenia

(Mood Disorder)

A
  • Schizophrenia
  • A severe, persistent, psychotic disorder with relapses throughout life
  • May be associated with fetal neurodevelopmental defects:
  • Viral infection during pregnancy
  • Prenatal nutritional deficits
  • Perinatal complications
281
Q

How to diagnose Schizophrenia

A

DSM 5: Two or more of the characteristic symptoms below are present for a significant portion of time during a one-month period (or less if successfully treated):

  • •1. Delusions
  • •2. Hallucinations
  • •3. Disorganized speech (eg, frequent derailment or incoherence)
  • •4. Grossly disorganized or catatonic behavior
  • •5. Negative symptoms, ie, affective flattening, alogia, or avolition
282
Q

•Attention-deficit/hyperactivity disorder (ADHD)

A
  • A neurobehavioral problem of impaired attention and hyperactive behavior affecting 5% to 10% of school-age children
  • Theorized that dopamine system disturbances may be associated with ADHD onset
283
Q

Dementia

A

•A chronic, slowly progressive disorder of:

  • •Failing memory
  • •Cognitive impairment
  • •Behavioral abnormalities
  • •Personality changes
  • Often begins after 60 years of age
  • Usually related to structural diseases of the brain
284
Q

Alzheimer type dementia

A
  • Approximately 60% of cases
  • May be caused by abnormal processing or deposition of amyloid
285
Q

•Vascular dementia

A
  • Approximately 5% to 10% of cases
  • Reduced cerebral blood flow such as a brain infarct(s)
286
Q

•Other dementias

A
  • Associated with diffuse Lewy bodies in the brain
  • Parkinson disease
  • Frontal lobe degeneration AKA Pick’s dementia
287
Q

What part of the brain is most at risk with substance use disorder esp in teens

A
  • Prefrontal cortex: Responsible for complex cognitive processes and not fully mature until young adulthood
  • Adolescents have increased vulnerability to substance use disorder
288
Q

When do you assess for potential substance abuse?

A
  • Routine: rapid screen for Tobacco, ETOH, and drug abuse
  • Patient presents with specific complaints
  • Patient is seeking highly addictive medications
  • Patient admits with s/s of drug abuse, withdrawal.
289
Q

SBIRT Model

A
  • Step one: In social history
  • Rapid screen: One question:
  • Tobacco: Do you smoke-> pack/year
  • ETOH: Do you drink. Yes-> how much how frequent.
  • If above limit: 2 standard drinks for men, and one for women daily, rapid screen is positive ->administer appropriate screening tool
  • FYI upper limit is less for senior: 1 standard drink for men or women, may drink up to 3 drink equivalent on accession not to exceed 7 drink equivalent a week
  • Prescription/illicit drugs:•“How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?” Any positive answer requires further more extensive screening
290
Q

Standard drink amounts

What is the legal limit for drunk driving?

If the patient weighs less than 200lbs he/she will reach BAC level after ____ standard drinks?

A

the legal limit for drunk driving is a blood alcohol concentration (BAC) level of 0.08.

If patient weight less than 200 pounds he/she will reach BAC level after two standard drink

291
Q

Any tool you perform during the medical encounter is considered an

A

Objective finding (even though it is a patient report)

292
Q

CAGE tool is for ______

A

ETOH only

293
Q

CAGE AID screening tool is for: _____________

A

Screening CAGE AID: ETOH and other drugs

294
Q

Screening Assist tool for:

A

All types of substance abuse

295
Q

DAST 10 screening tool is for:______

A

Drug abuse

296
Q

PHQ9 is for _____

GAD 7 is for _____

For elderly patients administer _____

A
  • Administer PHQ9 (depression) GAD 7 for anxiety
  • For elderly patient might be useful to administer MMSE or minicog
297
Q

•Four processes of Motivational Interviewing relevant to advanced assessment

A
  • Engaging: Used throughout assessments, including when resistance is encountered
  • Focusing: Attention to a patient problem and goal
  • Evoking: Process of evoking change talk from patients
  • Planning: Guiding the individual to form a concrete plan of action
298
Q

Important components of motivational interviewing are:

A
  • Important components of MI include empathizing and empowering the individuals to take steps toward change and affirming their strengths.
  • Provider must be genuine, honest, show empathy
  • Provider use open-ended questions, validation and affirmation and use of reflective listening
299
Q

5 A’s to Support Behavioral Change

A

Advise

Agree

Arrange

Assess

Assist

300
Q

DSM-5

very long

A

•DSM-5 criteria for addiction and nonsubstance addictive behaviors

  • •Assess for behaviors causing personal, emotional, social, financial, spiritual, or legal harm to individuals
301
Q

Stages of change:

Time frame of 6 months for the stages

Except for Stage 3 which is 30 days

A
  • Stage 1: Precontemplation is when an individual is not yet considering change or is unwilling or unable to change.
  • Stage 2: Contemplation occurs when the possibility of change is recognized but one is ambivalent and uncertain.

•Stage 3: Preparation or Determination is the stage in which the individual is committed to changing within 30 days but is still considering what to do.

  • Stage 4: Action includes taking steps toward change but the change is not yet stabilized.
  • Stage 5: Maintenance is the stage in which goals have been achieved and efforts are focused on maintaining the change.
  • Stage 6: Recurrence is defined as experiencing a recurrence or relapse of the old behaviors and deciding what to do next.
302
Q

Skeletal changes in older adults are the result of:

A

Increased bone reabsorption

ADV Health Assessment & Clinical Reasoning (4 decks)

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